(Affix patient identification label here)
URN:
Dr R E Pope
Family Name:
Beneficence and Nonmaleficence
Neurosurgeon and Spine Surgeon
Given Names:
Endoscopic Procedure and +/Endoscopic Third Ventriculostomy
Address:
Facility: .............................................................................................................................. ...............
A. Interpreter / cultural needs
An Interpreter Service is required?
Yes
No
If yes, is a qualified Interpreter present?
Yes
No
A Cultural Support Person is required?
Yes
No
If yes, is a Cultural Support Person present?
Yes
No
B. Condition and treatment
The doctor has explained that you have the following
condition: (Doctor to document in patient’s own
words)
............................................................................................................................................................................
............................................................................................................................................................................
This condition requires the following procedure.
(Doctor to document - include site and/or side where
relevant to the procedure)
............................................................................................................................................................................
............................................................................................................................................................................
Endoscopic procedure
C. Risks of this procedure
There are risks and complications with this procedure.
They include but are not limited to the following.
Common risks and complications include:
• Infection, requiring antibiotics and further
treatment.
• Minor pain, bruising and/or infection from IV
cannula site. This may require treatment with
antibiotics.
• Bleeding can occur and may require a return to
the operating room. Bleeding is more common if
Sex:
M
F
you have been taking blood thinning drugs such
as Warfarin, Asprin, Clopidogrel (Plavix or
Iscover) or Dipyridamole (Persantin or
Asasantin).
• Hormone dysfunction which can result in mood,
sleep and appetite changes requiring treatment
with hormones. This may be temporary or
permanent.
Uncommon risks and complications include:
• Heart attack due to the strain on the heart.
• Stroke or stroke like complications may occur
causing neurological deficits such as weakness
in the face, arms and legs. This could be
temporary or permanent.
• Epilepsy which may require medication. This
condition may be temporary or permanent.
• Failure to adequately control the circulation of
brain fluid. This may require further surgery.
• Small areas of the lung may collapse, increasing
the risk of chest infection. This may need
antibiotics and physiotherapy.
• Increase risk in obese people of wound infection,
chest infection, heart and lung complications, and
thrombosis.
• Blood clot in the leg (DVT) causing pain and
swelling. In rare cases part of the clot may break
off and go to the lungs.
Rare risks and complications include:
• Meningitis may occur requiring further treatment
and antibiotics.
• Vision can be affected by the surgery. This may
be temporary or permanent.
• Injury to the brain, important nerves or blood
vessels. This can lead to stroke like
complications.
• Fluid leakage from around the brain may occur
through the wound after the operation. This may
require further surgery.
• Death as a result of this procedure is very rare.
D. Significant risks and procedure
options
(Doctor to document in space provided. Continue in
Medical Record if necessary.)
............................................................................................................................................................................
............................................................................................................................................................................
Page 1 of 2
Continues over page ►►►
Procedural consent form
Endoscopic third ventriculostomy
The endoscopic procedure is a minimally invasive
procedure which gives access to the deepest part of
the brain using an instrument called an endoscope.
The procedure can be performed to:
- inspect the brain;
- biopsy/remove small tumours;
- drain/remove cysts and
- create bypass channels for circulation of
cerebrospinal fluid (CSF).
Endoscopic third ventriculostomy is performed as
an adjunct to the endoscopic procedure in order to
create an opening into one of the fluid filled cavities of
the brain called the third ventricle.
The procedure is performed to bypass any
obstruction to the flow of cerebrospinal fluid.
Date of Birth:
(Affix patient identification label here)
URN:
Dr R E Pope
Family Name:
Beneficence and Nonmaleficence
Neurosurgeon and Spine Surgeon
Given Names:
Endoscopic Procedure and +/Endoscopic Third Ventriculostomy
Address:
Facility: ..............................................................................................................................................
E. Risks of not having this procedure
(Doctor to document in space provided. Continue in
Medical Record if necessary.)
...........................................................................................................................................................................
...........................................................................................................................................................................
F. Anaesthetic
This procedure may require an anaesthetic. (Doctor
to document type of anaesthetic discussed)
...........................................................................................................................................................................
...........................................................................................................................................................................
G. Patient consent
I acknowledge that the doctor has explained;
• my medical condition and the proposed
procedure, including additional treatment if the
doctor finds something unexpected. I understand
the risks, including the risks that are specific to
me.
• the anaesthetic required for this procedure. I
understand the risks, including the risks that are
specific to me.
• other relevant procedure options and their
associated risks.
• my prognosis and the risks of not having the
procedure.
• that no guarantee has been made that the
procedure will improve my condition even though
it has been carried out with due professional
care.
• the procedure may include a blood transfusion.
• tissues and blood may be removed and could be
used for diagnosis or management of my
condition, stored and disposed of sensitively by
the hospital.
• if immediate life-threatening events happen
during the procedure, they will be treated
accordingly.
• a doctor other than the Specialist Neurosurgeon
may conduct the procedure. I understand this
could be a doctor undergoing further training.
I have been given the following Patient
Information Sheet/s;
About your Anaesthetic
•
Endoscopic Procedure +/- Endoscopic Third
Ventriculostomy
I was able to ask questions and raise concerns
with the doctor about my condition, the proposed
Date of Birth:
Sex:
M
F
procedure and its risks, and my treatment
options. My questions and concerns have been
discussed and answered to my satisfaction.
• I understand I have the right to change my mind
at any time before the procedure, including after I
have signed this form but, preferably following a
discussion with my doctor.
On the basis of the above statements,
I request to have the procedure
Name of Patient/
Substitute decision
maker and relationship: ............................................................................................................
Signature: ..............................................................................................................................................
Date: ....................................................................……………………………………………………
……...
Substitute Decision-Maker: Under the Powers of Attorney Act
1998 and/or the Guardianship and Administration Act 2000. If the
patient is an adult and unable to give consent, an authorised
decision-maker must give consent on the patient’s behalf.
H. Doctor’s statement
I have explained to the patient all the above points
under the Patient Consent section (G) and I am of
the opinion that the patient/substitute decisionmaker has understood the information.
Name of
Doctor: .............................................................................................................................. ......................
Designation: .........................................................................................................................................
Signature: ..............................................................................................................................................
Date: ....................................................................…………………………………………………………….
Name of
Anaesthetist: .............................................................................................................................. .........
Designation: .........................................................................................................................................
Signature: ..............................................................................................................................................
Date: ....................................................................…………………………………………………………….
I.
Interpreter’s statement
I have given a sight translation in
.............................................................................................................................. ............................................
(state the patient’s language here) of the consent
form and assisted in the provision of any verbal and
written information given to the patient/parent or
guardian/substitute decision-maker by the doctor.
Name of
Interpreter: ..........................................................................................................................................
Signature: ..............................................................................................................................................
Date:.................................................................... ……………………………………………………………..
Page 2 of 2
Consent Information - Patient Copy
Dr R E Pope
Endoscopic Procedure and +/- Endoscopic Third Ventriculostomy
Beneficence and Nonmaleficence
Neurosurgeon and Spine Surgeon
1. What is an Endoscopic Procedure and
+/- Endoscopic Third Ventriculostomy?
Endoscopic procedure
Endoscopic third ventriculostomy
The endoscopic procedure is a minimally invasive
procedure which gives access to the deepest part of
the brain using an instrument called an endoscope.
The procedure can be performed to:
- inspect the brain;
- biopsy/remove small tumours;
- drain/remove cysts and
- create bypass channels for circulation of
cerebrospinal fluid (CSF).
A small cut is made in the scalp over the site of the
underlying problem. A small hole is drilled into the
skull beneath the cut and the firm covering of the brain
is opened.
The endoscope is passed through the small hole into
the brain. Sometimes, it is necessary to create a small
pathway through the brain with the endoscope to
reach the problem. Using this technique, access to
parts of the brain can be achieved with relative ease.
When completed the endoscope is removed.
Endoscopic Procedure, Herston Multi Media Unit, RBWH, 2009
Endoscopic third ventriculostomy is performed as
an adjunct to the endoscopic procedure in order to
create an opening into one of the fluid filled cavities of
the brain called the third ventricle.
The procedure is performed to bypass any obstruction
to the flow of cerebrospinal fluid. To achieve this, the
endoscope is passed into fluid filled cavities
(ventricles) within the centre of the brain. The
endoscope is navigated into the third ventricle and a
small opening is made in the floor of the third ventricle.
This allows the excess cerebrospinal fluid to drain
away from the brain, relieving any pressure.
A small plastic tube (drain) may be inserted. This will
be removed within 24 to 48 hours.
The cut is closed with stitches or staples.
2. My anaesthetic
This procedure will require a General Anaesthetic.
See About your Anaesthetic information sheet for
information about the anaesthetic and the risks
involved. If you have any concerns, talk these over
with your doctor.
If you have not been given an information sheet,
please ask for one.
3. What are the risks of this specific
procedure?
There are risks and complications with this procedure.
They include but are not limited to the following.
Common risks and complications include:
• Infection, requiring antibiotics and further
treatment.
• Minor pain, bruising and/or infection from IV
cannula site. This may require treatment with
antibiotics.
• Bleeding can occur and may require a return to
the operating room. Bleeding is more common if
you have been taking blood thinning drugs such
as Warfarin, Asprin, Clopidogrel (Plavix or
Iscover) or Dipyridamole (Persantin or Asasantin).
• Hormone dysfunction which can result in mood,
sleep and appetite changes requiring treatment
with hormones. This may be temporary or
permanent.
Uncommon risks and complications include:
• Heart attack due to the strain on the heart.
• Stroke or stroke like complications may occur
causing neurological deficits such as weakness in
the face, arms and legs. This could be temporary
or permanent.
• Epilepsy which may require medication. This
condition may be temporary or permanent.
• Failure to adequately control the circulation of
brain fluid. This may require further surgery.
• Small areas of the lung may collapse, increasing
the risk of chest infection. This may need
antibiotics and physiotherapy.
• Increase risk in obese people of wound infection,
chest infection, heart and lung complications, and
thrombosis.
• Blood clot in the leg (DVT) causing pain and
swelling. In rare cases part of the clot may break
off and go to the lungs.
Rare risks and complications include:
• Meningitis may occur requiring further treatment
and antibiotics.
• Vision can be affected by the surgery. This may
be temporary or permanent.
• Injury to the brain, important nerves or blood
vessels. This can lead to stroke like
complications.
• Fluid leakage from around the brain may occur
from the wound after the operation. This may
require further surgery.
• Death as a result of this procedure is very rare.
Page 1 of 1